Feature Story

About 60 percent of men and 51 percent of women report suffering at least one traumatic event in their lifetime, and about two-thirds of children and adolescents will experience at least one traumatic event in their lifetime, according to the National Comorbidity Survey of mental health in the United States. The trauma could be a natural disaster like Hurricane Sandy or the recent Oklahoma tornadoes, a mass bombing or shooting like those at the Boston Marathon or Sandy Hook Elementary School, military combat, a motor vehicle collision, violent personal assault, the sudden death of a loved one, or being diagnosed with a life-threatening illness.

Post-traumatic stress disorder (PTSD) develops in up to a third of individuals exposed to traumas, according to the Institute of Medicine. Although about half of adults diagnosed with PTSD following a trauma improve without treatment in 1 year, 10 to 20 percent of these individuals develop persistent symptoms of PTSD, which can lead to job loss, familial discord, lower educational attainment, and suicide.

In many studies, therapy or medication reduced symptoms within 4 months, with some therapies having a large benefit, and certain medications having a small to medium benefit. The essential symptoms of PTSD are re-experiencing the trauma (e.g., intrusive memories or flashbacks); avoidance or numbing from thoughts, feelings, or activities associated with the trauma; or hyperarousal, for example, having an exaggerated startle response.

Psychological therapies are designed to minimize the intrusion, avoidance, and hyperarousal symptoms of PTSD by some combination of re-experiencing and working through trauma-related memories and emotions and teaching better methods of managing trauma-related stressors or coping. Numerous organizations have produced guidelines for the treatment of patients with PTSD.

Most guidelines, such as those from the Department of Veterans Affairs, Department of Defense, and the American Psychiatric Association, suggest psychotherapy as the first line of treatment for PTSD and medications as second-line treatment, but the current report had no direct evidence to support that conclusion.

"There is no convincing direct evidence from studies that randomize people to start with either medication or psychological therapy," notes Dan Jonas, M.D., M.P.H., an internist and co-director of the RTI International-University of North Carolina Evidence-based Practice Center that was funded by AHRQ to conduct the review. "It's not that we found evidence contradicting that psychotherapy should be the first-line treatment, but we also didn't find sufficient head-to-head studies to definitively confirm it. However, I do think it is a very reasonable approach, because there is a lot of evidence for psychological treatments that shows a pretty large benefit. In contrast, the amount of benefit found in drug studies is generally small or medium."

Exposure therapy has best evidence

The review found that exposure therapy had the strongest evidence for reducing PTSD symptoms. Exposure therapy had a large impact on symptom reduction and moderate impact on PTSD remission. Other psychological therapies that improved PTSD symptoms include cognitive processing therapy, cognitive therapy, cognitive behavioral therapy-mixed therapies, eye movement desensitization and reprocessing, and narrative exposure therapy.

"In contrast, the amount of benefit found in drug studies is generally small or medium." This is how clinical psychologist and report author Catherine Forneris, Ph.D., M.D., A.B.P.P., professor in the department of psychiatry at the University of North Carolina (UNC), Chapel Hill, explains exposure therapy. "Exposure therapy is used to treat a variety of anxiety disorders. In exposure therapy, you place yourself in the feared situation or a situation that comes close to the feared situation, and you allow yourself to get physiologically and emotionally aroused. You continue to ‘expose' yourself to the feared situation until the arousal goes down and you are able to retrain your body and mind that this situation is not as dangerous as you perceived it to be."

For example, if the trauma was a motor vehicle accident, the exposure would be sitting in the car, then driving on the road, then driving on the highway under conditions similar to the accident. That is in vivo exposure therapy. Therapists also use imaginal exposure therapy when it's too dangerous or impossible to recreate the situation, explains Forneris.

"This is when the person just thinks about the situation, for example, someone who has been in combat or experienced sexual assault. We focus on the images or aspects of the trauma frightening to them, talk about it out loud, or they may make an audio recording of their trauma narrative and then listen to it. That can be as powerful in some instances for generating the anxiety responses." The goal is to enable the person to eventually manage or extinguish the anxiety related to the trauma.

Cognitive therapy helps

Cognitive therapy is a type of psychotherapy based on the concept that the way we think about things affects how we feel and act. Says Forneris, "It's having patients recognize when and how their thinking is inaccurate or distorted, teaching them to hit the pause button, take a step back, and ask themselves what evidence they have that supports this thought as true or if it has been distorted in their mind because of the emotion associated with it."

She gives the example of a rape victim who takes blame for her assault because of what she was wearing at the time. Thereafter, she is reluctant to dress in a feminine way when going out with friends to a club. "We address the thought that she is somehow responsible for the attack, pointing out that she has dressed nicely hundreds of times before and she didn't get attacked," says Forneris. "Eventually she can reason that 'Just because I dress nicely is not an invitation for someone to hurt me. I'm going out with my friends who will support me if I feel uncomfortable.' It's helping her refocus on the reality, not what she thinks is reality based on her distorted thought and emotional response."

The review also found eye movement desensitization and reprocessing (EMDR) to be effective, which has an exposure aspect to it. Individuals imagine some aspect of the trauma until they get physiologically aroused. At that point, the practitioner uses a finger or wand and asks them to track something on a screen so that their eyes are moving very rapidly left to right.

"I don't think the underlying mechanism of EMDR is well understood, but there is something about that combination of the imaginal exposure coupled with the rapid eye movement that reduces the physiological and emotional responses and symptoms of PTSD," says Forneris.

Medications that work

Pharmacological treatments that improve PTSD symptoms range from antidepressants and mood stabilizers to antipsychotics. The AHRQ review found that five medications in particular reduced PTSD symptoms: fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine. Evidence for paroxetine and venlafaxine shows them to be effective for inducing remission of PTSD. This may be true for the other medications as well, but studies of other drugs did not typically report remission outcomes. Jonas and colleagues calculated from the studies reviewed that about 8 patients would need to be treated to achieve one PTSD remission using paroxetine or venlafaxine. These remissions generally occurred within 4 months of starting treatment and patients in the studies were typically 3 months or more beyond the trauma. All five medications had moderate strength of evidence supporting their efficacy in reducing PTSD symptoms.

"It would be possible for someone to conclude that the evidence suggests that paroxetine and venlafaxine have a larger benefit than the others, but that's not terribly definitive," cautions Jonas. "These five drugs have not been studied head to head, so this is an indirect conclusion. It looks like these five drugs work and as a clinician you have to pick one, and these two do have more evidence of benefit for certain outcomes."

How much do the medications help people? The review found a small to medium benefit, which was a 5 point to 15 point reduction in PTSD symptoms using a standard PTSD symptom measure, the Clinician Administered PTSD Scale. "Some argue that a 5 point reduction may not be clinically significant, but most agree that 15 points is a clinically significant reduction," explains Jonas.

Forneris practices in UNC's department of psychiatry, so many of her referrals come from people who are already on medication for their symptoms. "Medication has a role in treating PTSD, but therapy is very important too. I think that medications help stabilize people and help them start to reestablish their equilibrium such that they can engage in therapy. Trauma-related therapy can be difficult."

The goal is to get people's equilibrium established, with more regular eating, exercise, and sleep, and to make sure they have some basic coping skills before they start exposure therapy. "Initially, exposure therapy can be hard because it stirs up painful, disturbing, and frightening memories and emotions," explains Forneris. "It is not easy, but it's actually the most effective therapy. Ideally, when a person does exposure-based therapy, we need them to get physiologically aroused, and if they are on a medication that blunts these symptoms, it makes it difficult or impossible to do exposure therapy. So we try to get them off medication so that they can achieve an arousal that is uncomfortable, but necessary, in order from them to obtain benefit from the intervention."

"When I think of medications for PTSD, it is more to help quiet or restrict neurovegetative symptoms like poor sleep quality, muscular tension, gastrointestinal distress, and so on—symptoms that often accompany trauma. Medications, for example, can help someone achieve better sleep, but medication does not specifically target the trauma itself and the meaning they attribute to the event and its sequellae."

Both Forneris and Jonas point out that most studies on PTSD include individuals with different types of traumas and those with single traumas and multiple traumas. Therefore, more research needs to be done to find out which medications and therapies work for what types of populations or specific types of trauma.

Preventing PTSD

The RTI International-University of North Carolina Evidence-based Practice Center also recently completed a research review on prevention of PTSD among adults Interventions for the Prevention of Post-Traumatic Stress Disorder in Adults After Exposure to Psychological Trauma. The evidence for prevention was not very strong compared to the treatment report. The prevention report looked at interventions to prevent PTSD from developing among people who had symptoms within 3 months after the trauma. The evidence showed that debriefing of civilian victims of crime, assault, or accident trauma shortly after the traumatic event was not effective in reducing the incidence or severity of PTSD or depressive symptoms.

Says Forneris, co-author of the prevention report, "Many reports like ours conclude that debriefing is ineffective and can actually be harmful to people and should not be done. The fact that it continued to be used as an intervention to prevent PTSD shows that clinical uncertainty and controversy remains in the field as to how to prevent PTSD."

The report did find that in individuals with acute stress disorder, brief trauma-focused cognitive behavioral therapy was more effective in reducing the severity of PTSD symptoms than supportive counseling. There was insufficient evidence to draw conclusions about the effectiveness of medications to prevent PTSD since most of the medication studies were single-arm uncontrolled studies, notes Jonas. More and better prevention studies are needed.

Comments Forneris, "The biggest problem was we had over 2,500 studies we identified and we wound up with only 19 that had low to medium risk of bias.

Most of the 2,500 studies were not well done from a methodological perspective. In some respects this is understandable because of the conditions under which researchers are trying to conduct the studies." For example, researchers often must capture people quickly who may be displaced or recovering from physical injuries. They also must followup with them when their lives may be in a real state of flux. Forneris calls for better studies of preventive interventions that are universal or targeted to high-risk individuals. Right now clinicians do not know who is at high risk of developing PTSD after a traumatic event. It may vary by gender, by history of past trauma, or by type of trauma.

Says Forneris, "I hope this becomes a prolific area of methodologically sound research in the future. Thinking about recent events such as the bombings in Boston and the gun violence at Sandy Hook Elementary, I hope someone is designing good studies to follow those people so we can see if there is something we could have done—or will do—to prevent those involved from developing PTSD."

Editor's note: AHRQ's reports Psychological and Pharmacological Treatments for Adults With Post-Traumatic Stress Disorder and Interventions for the Prevention of Post-Traumatic Stress Disorder in Adults After Exposure to Psychological Trauma are available on AHRQ's Effective Health Care Program Web site at http://effectivehealthcare.ahrq.gov. You can read about AHRQ's report on Child and Adolescent Exposure to Trauma: Comparative Effectiveness of Interventions Addressing Trauma Other Than Maltreatment or Family Violence in the next article.